Private Health Insurance Decision Reference 2023-0079

Case OutcomeRejected
Year2023
Date31 March 2023
Reference2023-0079
Subject MatterPrivate Health Insurance
Finantial SectorInsurance
Conducts Complained OfClaim handling delays or issues,Rejection of claim – partial rejection
Decision Ref:
2023-0079
Sector:
Insurance
Product / Service:
Private Health Insurance
Conduct(s) complained of:
Claim handling delays or issues
Rejection of claim partial rejection
Outcome:
Rejected
LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN
The Complainant held a Health Insurance Policy with the Provider. The policy period in
which this complaint falls, is from 1 January 2019 to 31 December 2019. The complaint
concerns the Provider’s assessment of benefit payable under the policy, in respect of the
cost of medical treatment the Complainant’s son received in the UK, in October 2019.
The Complainant’s Case
The Complainant says her son, who is an insured person on her Health Insurance Policy with
the Provider, “has an unusual condition” and that as part of the investigation of this
condition, one of his treating physicians in Ireland advised that he “have a muscle biopsy in
[a named hospital in the UK] as they have equipment that is not available anywhere else in
the UK or Ireland”. The Complainant says another of her son’s treating physicians in Ireland
“verified that this level of testing was not available in Ireland”.
The Complainant sets out her complaint in the Complaint Form she completed, as follows:
“A muscle biopsy is done in the full hospital setting and done in theatre and involves
the thigh muscle being cut open and a section of muscle is taken for analysis. It is
done under full surgical protocol.
I had contacted [the Provider] to tell them [my son] was having this surgery and
wanted to claim under the medical tourism benefit … This benefit is payable up to a
maximum of €100,000, subject to preauthorisation, for medically necessary surgical
procedures in the EU. The level of benefit will be limited to the maximum level of
cover that your plan allows or a lesser amount if the overseas cost is less.

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